NHS considers organ donation shakeup

Among the options put forward by NHS Blood and Transplant for consideration is deploying new technologies to preserve organs after removal. Photograph: Graham Turner for the Guardian
Graham Turner/Guardian

The NHS is considering its biggest shakeup of the ethical, legal and professional rules governing transplants, floating ideas to prolong the lives of people who have no chance of surviving in order to harvest their organs, and to make people opt out rather than in to the donor register.

The options are included in a survey of medical, scientific and public opinion to be launched this week to test the boundaries of what might be acceptable, as a precursor to significant reforms.

The survey, on the NHS Blood and Transplant (NHSBT) website from Saturday with a deadline of 21 September, will also suggest:

• Giving priority for transplants to the 19.1 million registered donors in the UK.

• Deploying new technologies to preserve organs beyond the current method of packing them on ice.

• New financial rewards for intensive care units for every organ they provide. Hospitals currently receive about £2,000 per organ to cover their costs, which the NHSBT compares with the €7,000 (£5,500) paid in Croatia.

• Presuming consent unless people have actively opted out.

The NHSBT stressed that neither it nor the four health departments in the UK endorsed such ideas at present, but the results would inform future strategy on increasing transplants and organ donations.

The survey asks whether there should be a review of present professional practices of withdrawing treatment early so that patients stay alive longer. Most contentiously, it floats a rethink of elective ventilation of gravely ill patients whose deaths are inevitable, such as those who have suffered a catastrophic head or brain injury or stroke, in order to get more donated organs after brainstem death. The law on this issue has not been tested in UK courts.

This will spark a debate among clinicians, patients' groups and the public as it would overturn present practice that doctors do not go on providing treatment if they do not believe it is to an individual patient's benefit. The British Medical Association is also considering the idea of elective ventilation, but the NHS's canvassing of opinion lifts the idea far higher up the national and political agenda.

Sally Johnson, NHSBT's director of organ donation and transplantation, said there were questions over how doctors interpreted patient benefit. "What we want people to start thinking about is, if that person wants to be an organ donor, should you do your utmost to facilitate their final wish?"

Treatment withdrawal in the UK and other northern European countries tended to be more rapid than, for instance, in Spain, she said, where there was "a different interpretation of futility and what is to the patient's benefit".

NHSBT's associate medical director, James Neuberger, said that even if legal and ethical hurdles were cleared over elective ventilation, "we would only support it if in each individual case the family and relatives also supported it".

About 1,000 people die in the UK each year because they do not get a transplant, according to NHSBT. Johnson said more people wanted to become donors but the transplant service could not use all the organs they donated. More than 500,000 people die in Britain each year, but only about 3,000 in circumstances where they could realistically become organ donors.

"The reality is you have to die in hospital, on a ventilator, also in the intensive care or emergency department. The number of people dying who are under the age of 75, which is where most of our donors come from, has dropped by about 15% in the last few years. The people who are dying therefore tend to be older, they tend to have more co-morbidity than the rest of the population and, like the rest of the population, they have a tendency to be fatter. Consequently there are a number of people who would like us to use their organs but their organs might not be suitable."

There was also was an issue over whether the UK had enough intensive care beds, "not only to give people who are likely to survive a chance but also to fulfil their wishes for organ donation", Johnson said. "If we truly want to save as many lives as possible, then we are going to have to think whether we have got funding in the system to make that happen."

The survey asks whether the UK should follow Israel's lead and say that those who are on the organ donor register should get priority if they subsequently need a transplant. "It always seemed to me that fairness is quite a fundamental British value but we have never put that in the context of organ donation," Johnson said.

The NHSBT survey asks about extending the recently introduced practice by which the Driver and Vehicle Licensing Centre "nudges" those renewing or updating licences into deciding whether they want to join the donor register to other documents, such as marriage applications or wills. Johnson floated using the new universal credit, the single payment for those seeking work or on low incomes.

Transplant officials, who routinely stress that no transplant is risk-free, say there is promising research in the UK and abroad on better preserving organs such as kidneys, livers and lungs, and on using organs that would not have been previously used. A process called machine perfusion ensures organs get the necessary blood, oxygen and nutrients after removal and during transport.

NHSBT already uses smokers' lungs for transplants. Specialists from the service and the Association of Lung Transplant Physicians said in a Lancet article in May that this improved overall survival of patients registered for lung transplantation, and should be continued. Although lungs from such donors were associated with worse outcomes, an individual's probability of survival was greater if they accepted a smoker's lung rather than choosing to wait for an organ from a donor who did not smoke.

Last year nearly 4,000 organs were transplanted from nearly 2,150 donors. Increasing numbers of kidney transplants involve living donors.